Module II: Parenteral Nutrition

Question 1

It is common complication of central venous catheters inserted at bedside to have catheter misplacement, prior to use, recommended to

Answer 1

Verify correct placement of catheter tip with chest x-ray

Question 2

If central catheter is placed via fluoroscopy

Answer 2

PN can be started immediately without need for x-ray confirmation

Question 3

What PN component is most likely to impact anticoagulation in a patient receiving warfarin?

Answer 3

Lipid injectable emulsion (ILE) and vitamins
MVI for PN may or may not contain vitamin K
ILE is also a source of vitamin K, amount is variable

Question 4

Creaming of a total nutrient admixture (TNA) appears as

Answer 4

A translucent band at the surface of the emulsion separate from the remaining TNA dispersion. Creaming is the initial stage of emulsion breakdown

Question 5

Cracking of PN, terminal state of emulsion destabilization may include visual signs:

Answer 5

Yellow, brown oil droplets at/near surface
Continuous layer of yellow-brown Louis at the surface
Marbling or streaking of the oil throughout TNA

Question 6

Limited self care ability is disadvantage of what type of central access?

Answer 6

Peripherally inserted central catheter (PICC). Other disadvantages: high rate malposition and coiling, limited arm mobility, longer catheter which may be more prone to occlusion

Question 7

PICC line advantages include

Answer 7

No risk pneumothorax or puncture of internal carotid of subclavian arteries, available in single, double or triple lumens, repeated skin puncture not required

Question 8

Compounding of PN using a manual or automated device during which there are multiple injections, detachments, and attachments of nutrient source products to the device/machine to deliver all nutritional components to final sterile container is classified as

Answer 8

Medium risk per the US Pharmacopia Chapter 797

High risk includes non-sterile ingredients

Question 9

Most appropriate distal catheter tip placement of a peripherally inserted central catheter is:

Answer 9

Superior vena cava

Inserted via cephalic or basilic veins

Question 10

What complication is most likely to occur when transitioning a critically ill adult patient from parental to enteral nutrition?

Answer 10

Hyperglycemia - receiving overlap in nutrition sources and may result in excess above needs

Question 11

While receiving PN, patient develops metabolic acidosis. Which serum electrolyte level needs to be monitored most closely?

Answer 11

Potassium - metabolic acidosis may result in extra cellular shift of potassium

Question 13

Calculation of PN dosages has been associated with increase in ____________ errors related to PN formulation.

Answer 13

Prescribing. Other factors include: inadequate knowledge regarding PN therapy, certain patient characteristics related to PN therapy, miscalculation of PN dosages, specialized PN dosage formulation characteristics, and prescribing nomenclature

Question 14

In patients with hepatobiliary disease, which trace elements should be held or require dosage reduction in PN?

Answer 14

Copper and Manganese - due to impaired excretion

Question 15

True or false. Standard AA formulation in PN can be used in hospitalized patient with AKI

Answer 15

True

Question 16

Use of branched chain amino acid-enriched diets nutrition support formulas are only indicated in patients with

Answer 16

Chronic encephalopathy if cannot tolerate 1pm/kg/day of standard protein despite optimal pharmacotherapy

Question 17

What factor may reduce risk of calcium phosphate precipitation in PN?

Answer 17

Increased AA concentration. Forms complexes with Ca and limited available free Ca to bind with phosphate. Higher AA also reduces the pH which improves Ca-phos solubility

Question 18

When compounding PN, which is recommended to add first: calcium or phosphate?

Answer 18

Add phosphate first and then add calcium near the end of compounding so there is maximum dilution

Question 19

Storage under refrigeration increases or decreases risk of calcium phosphate precipitation?

Answer 19

Decreases the risk

Question 20

Infusion of PN >900 mOsm/L may lead to _______ if via peripheral catheter

Answer 20

Phlebitis

Question 21

Lower concentrated dextrose solutions (5-10%) and amino acids solutions (3%) are most often used for:

Answer 21

Peripheral administration
Osmolarity of 10% dextrose = 500 mOsm/L and 3% AA = 300 mOsm/L

Question 22

Cycling parenteral nutrition is recommended in patients

Answer 22

At risk for liver dysfunction. Or if long term and stable on PN

Continuous PN infusions can result in hyperinsulinemia and hepatic fat deposition, which increases risk of liver complications

Question 23

C

Question 24

What component of PN solutions is NOT a major source aluminum contamination?

Answer 24

Lipid injectable emulsion

Question 25

Large volume components of PN (AA, dextrose, lipids, and water) must contain < ________ mcg/L aluminum per the FDA

Answer 25

25 mcg/L

Question 26

SCCM/ASPEN 2016 critical care guidelines recommendations for energy for obese patients include

Answer 26

BMI 30-50: 65-75% target energy requirements per IC, or 11-14 kcal/kg ABW BMI >50: 22-25 kcal/kg

Question 27

Tetany (involuntary muscle contraction/spasm/tremor) may result from rapid IV infusion of

Answer 27

Sodium or potassium phosphate - due to abrupt decrease in serum calcium concentration

Question 28

Compared to DRIs for water-soluble vitamins given orally, the DRIs for parenterally administered water-soluble vitamins are

Answer 28

Higher. 2 to 2.5 times greater than RDA or AI due to increase requirements and increased urinary excretion of water-soluble vitamins when given IV

Question 29

The adverse effects of lipid injectable emulsion (ILE) administration on adult PN prescription is best prevented by

Answer 29

Using alternative ILEs. These may preserve liver function and prevent hypertriglyceridemia due to lower concentration soybean oil/phytosterols

Question 30

Dosage for all types of ILE are:

Answer 30

1-2 g/kg/day and should not exceed 2.5g/kg/day

Question 31

High output fistula is an indication for PN and is characterized by

Answer 31

>500 ml/day output

Question 32

SCCM/ASPEN critical care guidelines recommend ______ protein per IBW in critically ill obese patients

Answer 32

>30-40 BMI - 2 g/kg IBW >40 BMI - 2.5 g/kg IBW

Question 33

What is considered the most serious complication of significant hyperphosphatemia?

Answer 33

Soft tissue and vascular complications - calcification occurs when serum calcium level x serum phosphorus level exceeds 55 mg/dL Elevated phos may also cause hyper parathyroidism, renal osteodystrophy, and hypocalcemia

Question 34

Abrupt discontinuation of PN may result in

Answer 34

Rebound hypoglycemia, risk is higher in patients requiring insulin. Recommend 1-2 hours taper down of infusion to reduce risk

Question 35

The routine use of peri operative PN is indicated for patients with non-functioning GI tract who are

Answer 35

Severely malnourished

Question 36

Current CDC recommendations for PICC/central access line care include

Answer 36

Do not routinely replace Do not remove based on fever alone Use guide wire for catheter insertion for less discomfort and lower rate mechanical complication, but not for replacement

Question 37

ASPEN safety consensus recommendations consider what to be mandatory for the PN order form

Answer 37

Complete patient identifiers Birth date/age, Allergies, Height and weight dosing in metric units, diagnosis, indications for PN, administration/route, contact info for prescriber, date/time order submitted, admin date/time, volume and infusion rate, infusion schedule, and type of formulation. PN ingredients: amounts per day, electrolytes as complete salt form, full generic name for each ingredient, dose for each macronutrient, electrolyte, and vitamins, and trace elements, dose non nutrient medications if added

Question 38

ILE 20% contains _____ grams of fat/100 mL

Answer 38

20 g